Healthcare Provider Details

I. General information

NPI: 1831676980
Provider Name (Legal Business Name): LISA JACQUELINE KOVACEVIC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2018
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 NE NEFF RD STE 302
BEND OR
97701-4279
US

IV. Provider business mailing address

8203 W ORAIBI DR APT 2063
PEORIA AZ
85382-4696
US

V. Phone/Fax

Practice location:
  • Phone: 541-706-4220
  • Fax: 541-475-4805
Mailing address:
  • Phone: 619-322-2152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: